Right versus Middle Hepatic Vein access and One-Year TIPS Outcomes.

Area of Science:

• Interventional Radiology
• Hepatology
• Vascular Access Techniques

Background:

• Transjugular intrahepatic portosystemic shunt (TIPS) is a critical intervention for managing portal hypertension.
• The choice of hepatic vein access (middle vs. right) for TIPS placement is understudied, yet may influence clinical outcomes.
• Understanding the impact of hepatic vein selection is crucial for optimizing TIPS procedures and patient management.

Purpose of the Study:

• To compare one-year clinical outcomes of TIPS placement using middle hepatic vein (MHV) versus right hepatic vein (RHV) access.
• To evaluate the influence of hepatic vein access on shunt patency, patient survival, and the incidence of hepatic encephalopathy (HE).
• To assess the impact of access route on portal hypertension-related complications like ascites, hydrothorax, and gastrointestinal bleeding.

Main Methods:

• Retrospective chart review of adult patients undergoing TIPS with Viatorr stent graft between 2014-2022.
• Patients were stratified based on either MHV or RHV access for shunt creation.
• Intracardiac echocardiography (ICE) guided direct hepatic to portal vein access; shunts were dilated to achieve target portosystemic gradient (PSG) reduction.

Main Results:

• One-year survival (84% MHV vs. 75% RHV) and patency rates (96% MHV vs. 87% RHV) were comparable between groups.
• MHV access significantly reduced the incidence of de novo hepatic encephalopathy (30% vs. 62%, p=0.008), including moderate-to-severe cases (16% vs. 42%, p=0.017).
• Similar post-TIPS PSG reduction was achieved despite more frequent use of smaller diameter shunts (8mm) with MHV access; no difference in ascites, hydrothorax, or GI bleeding outcomes.

Conclusions:

• Both MHV and RHV access routes yield similar shunt patency, survival, and TIPS indication outcomes.
• MHV access is associated with a significantly lower incidence of hepatic encephalopathy.
• MHV may be the preferred hepatic vein access for TIPS, particularly in patients at higher risk for developing hepatic encephalopathy, while achieving comparable hemodynamic results.